Moving Away From Distressed Neighborhoods Improves Asthma Exacerbations in Children Living in Baltimore, Study Finds

A program that helped children with asthma and their families move into low-poverty neighborhoods resulted in a significant improvement in asthma symptoms and exacerbations and suggests that reducing housing discrimination can lower the prevalence of childhood asthma morbidity.

“That degree of improvement is larger than the effect we see with asthma medications,” said epidemiologist Elizabeth Matsui, MD, senior author of the study and a professor of population health and pediatrics at Dell Med, in a statement.¹ "We were also surprised to find that improvements in neighborhood stressors, including feeling safer in their new community and experiencing better social cohesion with neighbors, seemed to be major factors in the improvements in asthma.”

The results of this population-based cohort study were published in JAMA.²

Structural racism in the United States has resulted in a disproportional rate of childhood asthma among Black children, with 2 to 3 times the prevalence of asthma compared with White children. Despite knowing these barriers to care, current approaches to reduce the prevalence of asthma, especially among minority children, has had little impact.

Children were eligible to participate in the program if they had persistent asthma or had an asthma exacerbation within the past 12 months. These children and their families were included in a 6-year housing mobility program, known as the Baltimore Regional Housing Partnership (BRHP), which was founded because of a lawsuit that charged the Department of Housing and Urban Development (HUD) for being in violation of the 1968 Fair Housing Act.

In 2016, a total of 140 children were initially recruited, but 17 were excluded for not meeting eligibility criteria. As a result, 123 children ages 5 to 17 years, with persistent asthma living in Baltimore, MD, were enrolled in the study. Additionally, the children were matched with 115 children enrolled in the Urban Environment and Childhood Asthma (URECA) birth cohort using propensity scores.

The children enrolled at baseline had repeated home visits every 6 months, and phone calls every 3 months, relaying caregiver reports of the child’s asthma symptoms or exacerbations. These children had follow-ups for up to 12 months after their move, up until March 15, 2020.

Of the children enrolled in the study, median age was 8.4 years, 58 (47.2%) were female, 120 (97.6%) were Black, and 72 (60%) had at least 1 allergen sensitization.

Prior to moving, 89 of 110 (81%) lived in high-poverty neighborhoods, while only 1 of 106 (0.9%) lived in a high-poverty census tract after moving.

Additionally, 15.1% (SD, 35.8) of children had at least 1 exacerbation prior to moving v 8.5% (SD, 28) after moving, with an adjusted odds ratio (AOR, -6.8; 95% CI, -11.9% to -1.7%; P = .009).

Prior to moving, maximum symptom days in the past 2 weeks were 5.1 (SD, 5.0) before moving and 2.7 (SD, 3.8) after moving (AOR, -2.37; 95% CI, -3.14 to -1.59; P <.001).

Finally, the researchers found that the magnitude of reduction of exacerbations associated with moving was greater than that observed in individualized or household internventions among marginalized households, and had a 43% reduction rate, which was greater than that observed using inhaled cortcoseroids. Similarly, moving was associated with a 50% or more reduction rate, comparable to the effect of using biologc agents.

These results remained statistically significant after propensity score-matched analyses, with stress factors, such as social cohesion, neighborhood safety, and urban stress, all showing improvements with moving, and were estimated to mediate between 29% and 35% of the association between moving and asthma exacerbations.

The researchers acknowledge some limitations to their study, including the fact that it was not randomized, was based in one specific location, and was based on caregiver reports, which all could have led to bias and less generalizability.

However, the researchers believe that this study shows how moving out of distressed neighborhoods may reduce asthma symptoms and exacerbations just as well, if not more than other forms of interventions, including the use of inhaled corticosteroids and biologic agents.

“These findings confirm what we’ve long suspected: A big part of the asthma burden is not about who you are. It’s about where you live,” said Matsui in a statement.³ “This study demonstrates that programs designed to counter housing discrimination can have significant positive health effects for the children who move.”

References

1. UTAustin. Moving from distressed areas to better-resourced neighborhoods improves kids’ asthma. EurekAlert! May 16, 2023. Accessed May 17, 2023. https://www.eurekalert.org/news-releases/989213.

2. Pollack CE, Roberts LC, Peng RD, et al. Association of a housing mobility program with childhood asthma symptoms and exacerbations. JAMA. 2023;329(19):1671. doi:10.1001/jama.2023.6488